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HomeMy WebLinkAbout040-1162-60-000 ST. CROIX COUNTY ZONING DEPARTME ---- _ AS BUILT SANITARY REPORT Owner 60 i rr�rr Property Address City /State &yev cLi Legal Description: NING Lot Block Subdivision/CSM # ,c&L ' /a -zV 1 /a, Sec. z.C, T2LN -F,=-W, Town of PIN # _OYo a�o38. moo. (03/� SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/P / Setback from: House Well P/L Pump manufacturer Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fre air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: Tug / fAWI TWidth .3 Length , /-0 Number of Trenches -'>— Setback from: House > So , Well >s ' P/L Vent to fresh air intake .Sze ' ELEVATIONS Description of benchmark Elevation .Gz D Description of alternate benc lffma& _ we cW" zk Elevation .3 Building Sewer ST/HT Inlet ST Outlet PC Inlet — PC Bottom Header/Manifold �y3 Top of ST/PC Manhole Cover , 1 3 Fy Distribution Lines () 9,0 Bottom of System fb , -?9 ( ) Final Grade Date of installation,' &/ y ermit numbe .2 ( State plan number Plumber's signature License number Date 1111 Inspector arz Complete plot plan • ,. NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. 091e PLAN VIEW _r �S O —I tX64Q ,r'2 /° 1)\ y6v '` / a f #.) ✓EFt j,rti> — fou"✓i) �l�ru_ DEC IV1 - r/Z471/6 4 INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safet);and Buildings Divi sion J4, �/'o INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 39q ,— Permit H ( A der's Name ❑ City ❑ Village 9 Town of: State Plan ID No.: k6el VVA(V CST BM Elev.:- Insp. BM Elev.: B Description: Parcel Tax No.: ,I 41, 'too 1 Jn�� � 0 �o . j Ga -loo -wz7 TANK INFORMATION ELEVATION DATA A ° OUSE TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark ;t 166 Dosing ,_- P oi C6 " lod a10 7 q� Aeration Bldg. ewer ._ Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ._ Ventto TANK TO P/ L WELL BLDG. Air intake ROAD Dt Inlet .1 ,.._. Septic ( NA Dt Bottom Dosing NA Header / Man. a• Aeration Dist. Pipe i5 $ qt Holding ✓ Bot. System 10d Z. P3 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction. - System , TDH --Ft Forcemain Length Dia. I f Dist. To Well SOIL A RPTION SYSTEM BED kTRENO Width _3 1 Length o No. Of Trenches PIT No. Of Pits Inside Dia. DIME N (� DIMENSION SETBACK SYSTEM TO / DG WELL LAKE /STREAM LEACHIN nufacturer: INFORMATION Type O CH ER Model er: System - OR U DISTRIBUTION SYSTEM (yL ; (,�� �� �� �` W -3 (- Header /Manifold t Distribution Pipe(s) I Ll I x Hole Size x Hole Spacing nt To Air Intake Length I Dia. _ Length (i0 r Dia f ' Spacing it C K G SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed / Trench Center �` Bed /Trench Edges �- Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 31 Ste, SL,) h- &s5 S b c ►ice- 1 S - C d reg, WeA . ( , e, C' Ar Ct - 11YG� c.� ✓r,�W E �' lN6cJ� ��3c 0 � V I i Q Plan revision required? ❑ Yes Q No Use other side for additional information. -7- 7 11 6� E SBD -6710 (R.3/97) Date Inspector's S nature Cep Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County - Safe and Buildings Division INSPECTION REPORT ST . CRQ,j GENERAL INFORMATION (ATTACH TO PERMIT) SanitarBer�yQJq.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. _2e lioldefspd [ , j ] Village Town of: State Plan ID No.: 1 V / CSST B M E Elev.: 1 Insp. BM Elev.: BM Description: Parcel TCO :_:1162-60 -000 TANK INFORMATION ELEVATION DATA A9800544 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark a liw i Dosing .�& 7JC Aeration Bldg. SerWer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Air I ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header /Man. - 7C1a, Aeration NA Dist. Pipe Holding Bot. System fit, PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift [riction - System TDH Ft mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth. DIMENSIONS � � _ DIMEN I N SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Moe Numb System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 25.28.20,631E,SW,SW 118 BLACK BASS ROAD Plan revision required? ❑ Yes ❑ No (� Use other side for additional information. I SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION 201eE.WashngtonAve Division Asconsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanittaary Perm�iitt Number The information you provide may be used by other government agency programs E] Check if revision to`previ"'; application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 1 14 1 14, S T , N, R a E (or Property Owner's Mailing Address Lot Number Block Number Cit , State Zip Code Phone Number Subdivision Name or CSM Number GL wt t 2 ( a L II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms �— Town OF �/AS III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s 1 ❑ Apartment/ Condo , %1 -• //97 -- -- Cfl 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE ' OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2 ref Replacement 3. E] Replacement of 4_ E] Reconnection of 5. ❑ Repair of an System ______J_` System _____________Tank Only______________ Existing System _________E _____ - --- ---- -- B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed S63 -} r 7-,x4 ".❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12�Seepage Trench31* 8 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 Seepage Pit ,Z 3 X (D ` 43 ❑ Vault Privy 14 ❑ System -In -Fill LLS VI. ABSORPTION SYSTEM INFORMATION 3, 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Are 4. Loading Rate 5. Perc. Rate 6. System Elev 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) At� �,� c Elevation q5v ] ! T(1 S At Z „5 *0 Feet Capacity VII. TANK in Ca allons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existin Gallons Tanks Manufacturer s Name Concrete stoned Steel glass Plastic App A we If14FW F_,D Tanks Tanks k O Can �orurl ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber — ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of theZnsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb is S #P/MPRSW No.: Business Phone Number: Plumbe 's Address (Street, City, State, Zip ode): d o z! Zff, IX. COUNTY / QL USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination �' X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: X06398 (R t tom) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber . `� � (✓moo?/ S�� �fJ -�'7l/ � . x - p 1 j o p k i 0 n t _ M a a � 3 Q o � � � w k c .2m 1 IL W LL. �:3 z Wisconsin Department of Commerce SOIL AND SITE EVALUATION Divisiorrof Safety and Buildings Page �. of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in sve ,Plan most` County include, but not limited to: vertical and horizontal reference point (13W tton and percent slope, scale or dimensions, north arrow, and location and tapce to n f1 Parcel I.D. # di� APPLICANT INFORMATION - Please print all info"ationf; _- , a � � R iewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (.]) Property Owner Pa "dill li�j T)Ocation 1T Co rG��L� �w, 1.14 ��, 1 /4,S 2sT.?� .N.R E (o dL-•`! l�: Property Owner's Mailing Address Lot # - Block# ,. tubd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road ❑ New Construction Use: Residential / Number of bedrooms •3 Addition to existing building P Replacement ❑ Public or commercial - Describe: Code derived daily flow V5 gpd Pk Recommended design loading rate bed, gpd /ft trench, gpd /ft Absorption area required &Vi " fsed, ft trench, ft2 Maximum design loading rate .2bed, gpd /ft . Z? trench, gpd /ft Recommended infiltration surface elevation(s) #/ 1"3,6 ft 2.... 9o,S � ft (as referred to site plan benchmark) Additional design /site considerations 2 1 GGtT 4 Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U El (� U ❑ S O U El S �!] u ❑ S 2 u ❑ S VI U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench LS Zzf L s e- .7'.� 9�zs z 45 7• s— Sc M Fr AS z S Ground 3 t/ rJ1S O S r- L A,.J Z , Gr elev. y r ft. 7s /o - CS sG �t/1L J — .7 . e Depth to Al L' limiting factor > /yZ in. Remarks: 24 3 Boring # l f - Ground Q — c _ L F QBk F L GcJ elev. Depth to limiting factor Remarks: t y — v _/z CST Name (Please Print) Signature,.. r ` /y /ZrZ 1 _ Telephone No. AZ18ress I r Date CST Number d ,-"d 2o1z: z7 &,-r. e s 3 Z _ ,9Z < 1 U a.al�cP� PROPERTY OWNER �/ rE'Cc� SOIL DESCRIPTION REPORT Page -.2 of 3 PARCEL I.D.# O42- j% : .— Boring # Horizon Depth Dominant Color Mottles Structure G D/ft2 Texture Consistence Boundary Roots P in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed Trench / 0-7 /o-3/2- LC /yrf/z ,y-s• c . 7 .F 7-.?/ 7 —�/ 6 SL ,//Yfse/c _ Mr/a es 3G ,s elev.Ground 3 .7/ %3 7. S- 513 S / 5—-x /in dF/z • 7 . p.Ss ft. tl y3_60 S- y / L S © s� l�J�rL /7-w — . C D / Depth to 60-//1/.0 - 7 .S p/S _ m L . 7 .8 limiting factor Remarks: g C f - /9"/2 TT/.V To //a AtrvTre,z r.'l /{ofarzoit) Boring # #- y v.e545,t Ground elev. - ft. #/ T/zr-fry'/`f /1/,F, t) T_o .etc`` 10 w 54E G) TA/ . Depth to 9/ Lrf 7 S?47 04) _ T' JL rr 2 tool _ "G�I,' •' ;q v) limiting 577L1- "seArA i4J,4J fE/i¢/.4-7.77 J factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz. Sh. Bed Trench Boring # Ground elev. ft. Depth to - limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD-8330(R.07/96) y ts,t '. 1 �o ,1 To _ w l z C r � w b � I 1 x � ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC` TAN co o �� ._ � X This is to certify that I have inspected the septic 'aaT�J� presently serving the Ih kr�0 residence ec " at: S Section 3-6 , T_,�g N, R Town of - rro V Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. j ! $ 6Co cam. 6 `Ls 5 Last time serviced: 7 - oZ 6 - 9'�'5 Did flow back occur from absorption system? Yes X — No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: / L9 Construction: Prefab Concrete Steel Other Manufacturer: (If known): Age of Tank (If known): nature) (Name) Please print (Tl le) q (License Number) / d - 1 2 , C 6 0 Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP /MPRS ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �szDF�T' Mailing Address // d4,06k Property Address RZ4 - 4 F*a r r y A..g_ (Verification required from Planning Department for new construction) City/State _ SftIor r L Parcel Identification Number _ , V Ao LEGAL DESCRIPTION Property Location _s %., su/ ;, See. • Z 5 . T .Zp N -R : j e W, Town of TRo Subdivision Lot # Certified Survey Map # MP_r� .4 Aju6&W Volume , Page # Warranty Deed # 3vi.2 my Volume _ V7Y Page # y7-5_ Spec house ❑ yes [� no Lot lines identifiable 91 yes ❑ no SYSTEM MAINTENANCE Improper use and mains e n of your septic system could result is its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every flare years or sooner, if needed by a licensed pumper. What you put into the system can affect the fimetion of the septic tank as a treatment stage in the waste disposal system, The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner. and by a masterplumber, joumeyman Plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdnposal system ism proper operating condition and/or (2) after inspection and pumping (if necessary), the septic-tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. NANAlURE OF APPLICANT DATE OWNER CE1tTII'ICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in .Register of Deeds Office. NATURE OF APPLICANT DATE «es « *a Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department- '* Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed DOCUMENT NO. WARRANTY DEED STATe OF WISCONSIN —FORM 9 THIS SPACE RFSERVF.D FOR RECORDPIG DATA 11 di aJ THIS INDENTURE, made by C. E. Webster and Marian H. Webster, his wife 1 lath grantor s of St. Croix ! uf;tt t I 71 County, \lisconsin, hereby conveys and warrants 4 to Richard L. Varco - - 8:30 A, grantee RETURN TO of Ramsey County, Minnesota xc�ca,�c�axac .,umof Fifteen Thousand---------------- - - - - -- Dollars the followmE tract of land in St. Croix County, State of \Vi'con�in; � A parcel of 2.4 acres located in Government Lot 1, Section 25, and in Government Lot 1, Section 36, all in Township 28 North, Range 20 West, further describ (-d as follows: From the Northeast corner of said Government Lot 1 Section 25 go South a distance � of 50.0 feet; thence West parallel with the North line of said Government Lot 1 a distance of 400.0 feet; thence South 24 West a distance of 325.0 feet; thence South 10 East a distance of 890.0 feet to the POINT OF BEGINNING for parcel to be conveyed herein; thence South 31 0 15' East a distance of 280.6 feet; thence South 76 West a distance of 408.5 feet; thence North 23 West on a meander line along the shore of �I Lake St. Croix a distance of 199.4 feet; thence North 57 °00' East a distance of 381.4 feet; thence South 10 East a dis- tance of 53.2 feet to the POINT OF BEGINNING including din all g land between said meander line and Lake St. Croix and an easement for an access road to the above described parcel North and East to connect to the town road as now travelled. Parcel is subject to an easement for an access road over and across the East edge of said parcel as now opened and travelled. ' jS. 00_ IN VVITN!;S ;S NVIiERE01', the i.r.d ^raptor S ha Ve herenno wt their iian:! -S aml sc.sl S thi= 15th day of July 71. NED AN4) SEALED IN PRESENCE: of -__� _ (SEAL) - -- - �z C. E. Webster (sEAL) P. D. L rsen Marian H. Webster i (SEAL) Ii i Donna M. 01stad � (SEAL) II !I STATE OF WISCONSIN, SS. St. Croix _ Conaty.} Personally came brfore me, this 15th dnv nr July A n to 71